Coronial Inquests

Developed by Joanne Purdue & Ally Kerr –

Professional Officers, NSWNMA

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This presentation discusses some very sensitive topics including mental health, suicide, drugs and alcohol and death which some may find distressing.

If you are experiencing distress, please contact the Nurse and Midwife Support who are available 24/7 on 1800 667 877 or at nmsupport.org.au.

You can also contact Lifeline on 131 114 for confidential help.

TRIGGER WARNING

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Role of the CoronerCoroners investigate certain kinds of deaths in order to determine….

• the identity of the deceased,

• the date, place, circumstances and medical cause of death

The Coroner’s role is to find out what happened, not to point the finger or lay blame.

In some cases, inquests are held and witnesses are called to give evidence of their knowledge of the circumstances of the death.

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Role of the Coroner

The Coroner cannot find someone guilty of a crime.

During the course of an inquest / inquiry, if the Coroner forms an opinion that a known person has committed an indictable offence

– in connection with the death –the Coroner is required to suspend the inquest / inquiry

and refer the matter to the Director of Public Prosecutions.

Then becomes a matter for the Director of Public Prosecutions >> determine whether charges should be laid >> criminal courts to determine whether the person is guilty.

If practice is found to have deviated from

professional standards >> can be referred to HCCC

for investigation.

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Coronial Inquests

• An important tool to continue to improve the provision of care to the public – identify ongoing deficits in the system which place the public at risk of harm.

• Nurses and midwives should seek legal advice prior to providing the police with a statement in a coronial investigation.

• The Coroner can refer a nurse or midwife to the Health Care Complaints Commission (HCCC) for investigation.

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Role of the Coroner

The Coroner can make recommendations to try to prevent from future deaths/adverse events in similar circumstances.

Usually around deficits in the system which place the public at risk of harm.

Name

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Coronial Inquests

The Coroners Act 2009 (NSW) governs the conduct of these proceedings.

Police investigate “Reportable Deaths” under section 6 on behalf of the Coroner.

Reportable Deaths include but are not limited to: • A violent or unnatural death or a death where the cause is unknown;• A death in suspicious or unusual circumstances;• The death of a person who had not been seen by a medical practitioner within 6 months prior to the

date of death;• A death that was not the reasonably expected outcome of a health-related

procedure carried out;• The death of a resident of a declared mental health facility whether

the death occurred in the facility or during a temporary absence from the facility.

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Recommendations

Recommendations are not binding, but they are influential.

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I recommend that the LHD provide ongoing periodic training to all mental health clinical staff in relation to the need for a holistic consideration of the needs of a patient in determining the level of observation that is to be afforded to a patient.

I recommend that the LHD provide increased and regular education and training to nursing staff within mental health units regarding completion of patient observation charts to ensure that observations are accurately recorded at the times that they are performed, and to avoid the practice of “block recording” where observations are recorded collectively and subsequent to the time of the actual observations.

Examples of recommendations for a LOCAL HEALTH DISTRICT

Recommendations

I recommend that the LHD develop policies and procedures to clearly identify the roles and duties of incoming and outgoing nursing staff within mental health units during handover times. In particular, I recommend that any such policies and procedures clearly identify the nurse responsible for performing observations of patients that occur during handover times.

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I recommend that the NSW Minister for Health give consideration to increasing nurse-to-patient ratios within the Psychiatric Intensive Care Unit of the Hospital, to ensure that patient safety is not compromised.

RECOMMENDATIONS for the NSW MINISTER FOR HEALTH

Recommendations

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After a Death

• Must ensure that everything is left in-situ (catheter bags, fluids, lines, drains).

• If you believe it is a reportable death, then you must report it to the Police or ensure an appropriate person reports it.

• After a death is reported to the Police the police will investigate the circumstances of the death.

• The investigation will include obtaining statements from staff, obtaining an autopsy report and seeking expert reports.

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After a Death

• If a inquest is held, you may be required to give evidence in court –seek advice and representation from the NSW Nurses and Midwives’ Association

• In most circumstances, a coroner will allow a witness in an inquest to be legally represented.

• Autopsy – can be external and visual.

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Making a Statement

• A nurse or midwife who is approached by an employer, the employer’s representative or the police has the right to seek advice.

• This can be from the NSW Nurses and Midwives’ Association and advice should be received prior to writing or submitting any statements.

• The nurse or midwife should indicate that they are willing to assist and co-operate once they have had the opportunity to seek advice.

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Making a Statement Assistance provided by the NSWNMA: • After initial contact the matter will be referred to a NSWNMA Legal Officer, they will then contact the

nurse or midwife and advise accordingly.

• The nurse or midwife has a right to view the patients health care records in respect to entries they may have made, this enables them to refresh their memory of care they may have provided and allow a more accurate statement to be prepared. Please do not access a medical record – this will be arranged by your legal representative.

• Statements – if not giving a statement can be subpoenaed.

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Statements - Right to Silence

• Nurses and midwives have a right to remain silent.

• Nurses and midwives have the right to seek legal advice and assistance, this is during both internal and external (police) investigations.

• If a nurse or midwife is contacted by police, HCCC, NMC or AHPRA they should immediately contact the NSWNMA.

• Cooperate with the investigator/investigation, but DO NOT provide a statement or attend an interview without legal advice first.

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Nurses and midwives have the right to seek legal advice from their Association/union first.

DO:• Contact the NSWNMA and seek legal advice

and assistance before acting.

DO NOT:• Give or sign any statements before receiving

advice and assistance from a NSWNMA Legal Officer.

• Attend or be interviewed without a support person or advice from the NSWNMA.

• Be pressured into providing or signing statements without advice from a Legal Officer.

• Rely on memory alone when giving or providing statements (many years may have passed).

• Access medical records without proper authority.

Statements - Right to Silence

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Lack of documentation leaves a nurse or midwife’s action open to interpretation

a patient’s/woman’s health care record will be central to any decision-making around care received.

Remember, good documentation will aid in writing a complete and accurate statement.

Statements - Right to Silence

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NSWNMA Professional Assistance

NSWNMA offers members assistance and advice with professional and practice issues.

Medications query or dilemma and need clarification on professional obligations

Practice issue or medication issue and need to know your legal and professional obligations

Legal advice and representation (for matters relating to your practice of nursing or midwifery)

Professional representation and advice on professional standards, codes and guidelines

www.nswnma.asn.au

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